Health Financing for Universal Health Coverage: Messages ... · traditional notions of...
Transcript of Health Financing for Universal Health Coverage: Messages ... · traditional notions of...
Health Financing for Universal Health Coverage: Messages for South Africa?
Joseph Kutzin | Coordinator, Health Financing | Health
Systems Governance and Financing www.who.int
Presidential Health Summit
Johannesburg, South Africa. 19-20 October 2018
Operationalizing UHC
WHO’s approach to health financing
Some lessons from experience with potential
relevance to South Africa
Overview
UHC and public policy
UHC, defined
Enable all people to use the health services
that they need (including prevention,
promotion, treatment, palliation and
rehabilitation) of sufficient quality to be
effective;
Ensure that the use of these services does not
expose the user to financial hardship
• World Health Report 2010, p.6
Making it operational: a direction, not a destination
“Moving towards UHC” means progress on one/ some/all of the following (progressive realization)
• Reducing gap between need and use (equity in use)
• Improving quality
• Improving financial protection
Offers practical orientation for policy reforms
• Approach relevant to all countries
• What are the ways that we are under-achieving on these goals? What obstacles to progress must be addressed?
• Reform needs to be about solving problems, not picking a model
UHC changed (or should have) the basis for public policy on health coverage (1)
Coverage as a “right” (of citizenship,
residence) rather than as just an employee
benefit
• A major but often unrecognized shift in the logic
that prevailed prior to WW-2
• Critically important implications for choices on
revenue sources and the basis for entitlement
NHI in the UK,
1911
Risk covered by
“health insurance”
was loss of wages
when ill and
unable to work
(protection for
workers, not
entire population)
This rationale no
longer applies! Source of slide: Sarah Thomson, WHO Barcelona Office
Progressive de-linkage of health coverage from employment status
Shift in revenue mix from specific contributions for health insurance to general government revenues
LMICs – all recent coverage expansions reflect this approach
• India, Indonesia, Gabon, Thailand, Mexico, Peru, China, Philippines, Ghana…
What UHC implies for revenue sources and entitlement
Many HICs also moving towards “tax-funded health insurance”
Source: Szigeti et al (forthcoming). WHO/Hungary Country Office
UHC changed (or should have) the basis for public policy on health coverage (2)
Unit of Analysis: system, not scheme
• Effects of a “scheme” or a “program” is not of interest per se; what matters is the effect on UHC goals considered at level of the entire system and population
• Assess goals embedded in UHC at the population level…
• …because a scheme can make its members better off at the expense of everyone else
UHC is an explicitly political agenda, because it requires redistribution
WHO’s approach to health financing
Regardless of label, all health financing arrangements involve
• Revenue raising
• Pooling of funds
• Purchasing of services (allocation to providers)
• Policy (explicit or implicit) on benefit entitlements and rationing
It is not the case that the Germans are “more insured” than the British just because their system carries the label “insurance”
The functional approach
We care about how well financing arrangements “insure” their populations
• Promoting use in relation to need, financial protection, and quality
• Countries need to tailor their financing arrangements to their context, guided by these objectives
• Almost certainly, South Africa’s NHI will not conform to traditional notions of “insurance” – you have choices
We don’t care what you call it – whatever works to communicate effectively with your people
• Think/plan with functions, sell with labels
What we care (and don’t care) about
Health financing for UHC: some lessons from experience
with potential relevance to South Africa
Build foundations for more equitable, efficient,
transparent, and adaptable health system
• Choices made for implementation steps should
reflect this
• Avoid “locking in” inequalities and inefficiencies
that will be hard to undo in the future
• There is no magic to NHI or UHC; it will take hard
work (reflected in the proposed Commissions)
Messages/lessons for the transitional implementation
1. Accountability and public reporting
2. Design in equity and universality from the
beginning
3. Address areas of potential conflict of interest
4. One health system per country
5. Combine central guidance with managerial
flexibility (results, not “compliance” and control),
to move towards a data-driven, thinking health
system
Some criteria/principles to guide implementation
Reducing fragmentation and strengthening
purchasing power is the great potential
advantage of single payer arrangements
• Many good examples (Costa Rica, Estonia, Turkey,
Hungary, Lithuania, Kyrgyzstan, Moldova,
Philippines, and most recently Indonesia)
But putting all the money in one place is also
a risk (Kazakhstan’s experience in late 1990s)
1. Accountability, transparency, reporting
Mandatory public
reporting on the use
of funds and results
achieved by the new
NHI agency
There are good (great)
examples from which
to learn
This is non-negotiable
https://www.haigekassa.ee/en/organisation#tab-annual-reports
If you start with the formal sector using contributory-based entitlement, you will “lock in” segmentation
• Vested interests block unified approach including informal sector and poor
• Even the reformers in Mexico and Thailand could not fully overcome the legacy of the historical link of health coverage to employment
Avoid separate public schemes/pools for different population groups – that’s a recipe for long-term inequity and inefficiency
2. Design universal, pro-poor approach into early implementation
Unify information platform on patient activity, regardless of insurance affiliation status
• Technical foundation for universal system (Kyrgyzstan, Korea, Maryland/US)
Get diversity in the pool and common benefits at first stage (e.g. formal and poor, formal and informal), even if you can’t get everyone in immediately – set the precedent (Moldova, Kyrgyzstan, Indonesia)
Practical steps to lay foundation for a universal system
This is a fundamental governance responsibility
for those leading the health system
Conflict of interest is a source of inefficiency and
potentially “bad medicine”
• USA: physician owners/investors of hospitals and
diagnostic centres to which they refer (a poor county
on Texas-Mexico border has highest Medicare costs in
the country as a result of this)
3. Address conflict of interest…NOW
Chinese public hospitals: incentives aligned to induce unnecessary tests
All staff of the hospital are investors in the CT
scanner with objective to maximize its use
Source of slide: Prof. Winnie Yip
China vs Thailand during 2000s
• Both greatly increased public spending and affiliation
to health insurance programs
• In Thailand, service use and financial protection
improved due to coherent, closed end provider
payment policies that managed spending growth.
• NOT the case in China: open-ended fee-for-service
with percentage co-payments shifted money to
providers, and burden to patients
More generally: why you can’t just spend your way to UHC
Conflict of interest in South Africa? As medical scheme expenditure increases, so do the earnings of Administrators
• No incentive to control cost growth
• No incentive to see a 70% c-section rate as a problem
• No incentive to move away from open-ended fee-for-service reimbursement
So premiums rise and benefits shrink – consequences of this inefficiency are shifted to patients (and employers, including government)
Is there a way to alter these incentives so that they are aligned with public policy concerns?
4. One country, one system
Technical perspective
• The public and private delivery and financing
arrangements in the country, like any country, have
interactions and spillovers
Political perspective
• The core foundation for NHI is a recognition that
the financing and delivery “architecture” of the
health system has not changed much since 1994
Source: WHO Global Health Expenditure Database
Globally, South Africa is an extreme outlier: do we care?
VHI is not necessarily a problem, but here in SA, it’s a driver of system inequity and inefficiency
Country
Voluntary health insurance Population coverage
Share of health spending
Role
France 90% 14% Complementary Slovenia 84% 16% Complementary UK 9% 4% Supplementary Kenya 1-2% 12% Duplicative South Africa 16-17% 47% Duplicative
Population coverage with VHI compared to
percent of health spending via VHI
Source of European VHI population coverage data: Sagan and Thomson 2016;
data for latest available year
Spillover effects
• diversion of scarce (especially human) resources to serve
the insured, at expense of the poorer population
• High prices also push up input costs across system
• Fiscal impact – premium increases for civil servants
Harming patients
• Some of the high costs are due to dangerous practices (e.g.
70% c-section rate for privately insured)
What is South Africa, and what do you want it to be?
• Since 1994, public policy based on this being one country
Why the private medical sector is a public policy concern
5. From “command and control” to local problem solving within clear policy framework
Focus on accountability for results, not control of
inputs or just executing budget line items
Central planning is good for setting high-level
objectives, but not for responding to diverse
needs of a large country in a timely manner
Many countries have had success with “managed
autonomy” as well as harnessing the brainpower
of local managers
For example
Ghana in the 1990s
• Each Regional Directors of Health Services was encouraged to establish an Operations Research Unit to investigate and develop local solutions to local problems
• Empowered District Health Teams (which formed part of the Unit)
In Mexico’s decentralized system
• Annual meeting of State Health Departments to review comparative performance data and share experience with changes introduced
A specific health financing issue
The gains from “strategic purchasing” can only be
realized if managed have some degree of
autonomy to manage their internal resources
• Partial autonomy over reimbursements from single
payer agency in Kyrgyzstan enabled hospital managers
to make large efficiency gains in 2001 that translated
into lower informal payments for patients
• Autonomy was not a “giveaway”, and is not “all-or-
nothing”; providers still had to report on the use of
funds and had some limits on their spending decisions
Creation of outpatient drug package in Kyrgyzstan
Inpatient database showed high number of cases
for PHC-sensitive conditions
Led MHIF and MOH to develop reform
• Outpatient drug package targeted at four conditions
(e.g. hypertension)
• Dissemination and monitoring of implementation of
new clinical guidelines for these conditions
• Ongoing monitoring and adjustment over the years
Estonia changed its PHC payment system in response to new challenges and more/better data
Capitation74.3%
Basicallowance12.6%
Investigationsfund
12.6%
Distancefee0.4%
2003
Capitation55.0%Basicallowance
14.1%
Investigationsfund
20.0%
Distancefee0.6%
2ndnursefee5.2%
Activityfund0.7%
Therapeuticfund1.3%
Qualitybonus(P4P)
2.7%
Outofofficehourspay0.4%
2017
All costs are covered through these different payments Over time the role of capitation has decreased Fee for service (mostly with cap) part increases continuously enabling
family doctors to take more role over patient care New incentives: P4P, out of office hours fee, 2nd nurse fee
Source: www.haigekassa.ee
Implement, evaluate, learn and adapt
Need good plan, but recognize that “s_ _t happens”
• Not everything can be anticipated
• Circumstances vary around the country
• Circumstances and needs change over time
Move towards a data-driven, adaptive system
• Unified national provider payment database is a tremendous potential resource
• So is the excellent applied research capacity that exists in South Africa
Government needs to steer these to a common purpose
Final reflections
Financing can’t do it alone; it takes a system
The proposed Commissions recognize this –
completely agree
The different pieces have to be aligned while
not “over-designing” from the central level
• More art than science, but can approach it
systematically
Reminder
Improve quality in the public sector
Manage cost growth in the private sector
[He says it better than I do, and certainly more
concisely]
Minister’s sound principles to guide implementation of NHI in South Africa
Summary messages
Guide specific
implementa-
tion steps by
clear criteria
Design in
universality
from the
beginning
(UHC=unified)
Commit to
transparency
and public
accountability
Don’t be
constrained by
traditional
notions of
insurance
Put in place
foundations
for equity and
efficiency
Implement,
evaluate, learn
and adapt:
ensure space
for flexibility